Choose the right treatment, at the right dose – a way to create a financially-sustainable cancer care?

The costs of immunotherapy are higher than standard chemotherapy treatment it is replacing for many tumour types. As novel effective immunotherapeutics are continuously made available, medical oncologists need to counterbalance their aim of providing the best outcomes for cancer patients with the fact that global healthcare systems do not have limitless financial resources that may sustain the higher costs of treatments.

Quantifying treatment costs is critical for building financially sustainable healthcare so we can see how resources are currently used and to support realistic future planning. An example of this type of analysis is presented at the ESMO Congress 2024 (Barcelona, 13–17 September), where researchers from the Netherlands identified that costs for immune checkpoint inhibitors (ICIs) used to treat solid tumours had increased 4-fold from 2017 to 2023 (Abstract 1535O). While the specific numbers cannot be extrapolated to other healthcare systems as each country has different economics, this study clearly illustrates the trend of increased spending year-on-year as we evolve our standards of care.

Building sustainability can also be achieved by ensuring that new treatments are used where there are the greatest benefits. This same study also showed that the majority of the ICI budget was spent on indications where there was an established clinical benefit, with 83% of the budget spent on indications with ESMO Magnitude of Clinical Benefit Scale scores of 4 or 5, and A or B, indicating substantial clinical benefit in the non-curative and curative settings, respectively. This highlights the value of using validated tools to ensure new treatments are used where clear benefit has been demonstrated.

Reducing the cost of therapy through dose optimisation may also be a useful sustainability strategy. Using lower doses through a process of dose optimisation could be a valuable approach to minimising spending on novel treatments, as long as there is evidence for equal clinical benefit with lower doses. Different approaches to dose optimisation are being studied, including low-dose therapy, and changing to a weight-based dosing regimen. Interim results of an ongoing non-inferiority study comparing low-dose with standard-dose ICI are presented at the ESMO Congress 2024 (Abstract 1258MO). Studies like this will be invaluable for informing future economic strategies. We await the final results with great interest to see if the low-dose ICI approach matches the efficacy of standard dosing.

Meanwhile, there is an increasing number of researchers investigating whether weight-based dosing of immunotherapies – as used with many standard chemotherapies – would be at least as effective as the standard flat-dose approach used in clinical trials. As with lower doses, weight-based dosing offers the potential to reduce the overall amount of treatment used and so streamline drug costs (J Glob Oncol. 2019;5:1–5; Br J Cancer. 2023;129:1389–1396).

Finally, to move away from the currently predicted model of unsustainable exponential year-on-year cost increases, we need more clinical studies that assess cost and value to guide us on the best strategies to use our resources both nationally and globally. With the right clinical evidence supporting decision-making, we can create a sustainable healthcare system that achieves high-quality clinical outcomes for patients while containing costs.